Providing Cross-Gender Hormone Therapy for Transgender Patients
Gal Mayer, MD
April 30, 2013
This publication was produced by the National LGBT Health Education Center, The Fenway Institute, Fenway Health with funding under cooperative agreement # U30CS22742 from the U.S. Department of Health and Human Services, Health Resources and Services Administration, Bureau of Primary Health Care. The contents of this publication are solely the responsibility of the authors and do not necessarily represent the official views of HHS or HRSA.
Polling Question 1
I currently provide the following services to my transgender patients: a) Mechanism by which to indicate gender pronoun
and/or preferred name that is then used by staff b) Gender neutral or unisex bathrooms c) Cross-Gender Hormone Therapy d) Transgender-experienced mental health care (direct
or by referral) e) Referral to surgeons f) Assistance (direct or by referral) with legal
name/gender marker change g) I do not serve any transgender patients.
Please check all applicable answers in the polling box on your screen. Click “submit” when finished.
Polling Question 2
The barriers to providing these services include: a) I did not know the service(s) was important b) Lack of institutional support c) I have not been trained in how to provide the
service(s) safely d) Concern about insurance coverage issues e) Concern about medical liability f) I do not know how to locate appropriate resources in
my community g) Concern about opening a “Pandora’s Box” of problems h) I do not serve any transgender patients
Please check all applicable answers in the polling box on your screen. Click “submit” when finished.
Continuing Medical Education Disclosure Program Faculty: Gal Mayer, MD Current Position: (former) Medical Director, Callen-Lorde
Community Health Center Disclosure: No relevant financial relationships. Virtually all
mentioned uses of the hormonal medications contained in this presentation are not FDA-approved and considered off-label.
It is the policy of The National LGBT Health Education Center, Fenway Health that all CME planning committee/faculty/authors/editors/staff disclose relationships with commercial entities upon nomination/invitation of participation. Disclosure documents are reviewed for potential conflicts of interest and, if identified, they are resolved prior to confirmation of participation. Only participants who have no conflict of interest or who agree to an identified resolution process prior to their participation were involved in this CME activity.
Learning Objectives
Describe how to create a welcoming, inclusive environment for transgender people seeking hormone therapy.
List ways to provide cross-gender hormone therapy to transgender people by understanding their effects, benefits, risks, and administration.
Access additional resources for offering effective medical care for transgender people.
Callen-Lorde Community Health Center, NYC
Primary care Cross-gender hormone therapy HIV care Oral health care Gynecology/women’s health Mental health/social services Sexual health clinic Adolescent health Mobile health
356 West 18th Street New York, NY 10011 www.callen-lorde.org
Polling Responses
1. I currently provide the following services to my transgender patients: a) Mechanism by which to indicate
gender pronoun and/or preferred name that is then used by staff
b) Gender neutral or unisex bathrooms c) Cross-Gender Hormone Therapy d) Transgender-experienced mental
health care (direct or by referral) e) Referral to surgeons f) Assistance (direct or by referral)
with legal name/gender marker change
g) I do not serve any transgender patients.
2. The barriers to providing these services include: a) I did not know the service(s)
was important b) Lack of institutional support c) I have not been trained in how
to provide the service(s) safely d) Concern about insurance
coverage issues e) Concern about medical liability f) I do not know how to locate
appropriate resources in my community
g) Concern about opening a “Pandora’s Box” of problems
h) I do not serve any transgender patients
Terminology and medical “transition”
The Process of “Transition” or “Affirmation” The process from living and being perceived as the
gender assigned at birth according to the anatomical sex (M or F) to living and being perceived as the individual sees and understands themselves
Does not necessarily include surgery or hormones Transgender identity transition can be similar to the
LGB “coming out” process Many prefer the term “gender affirmation” or “gender
confirmation” over “transition”
Terminology and medical “transition”
Transition/Affirmation (cont’d) Some transitions have milestones (living part-
time, living full-time, etc.) and an endpoint, while others are continual processes
Transitions happen on many levels: hormonal, linguistic, psychological, intellectual, spiritual, surgical, social, emotional, legal, etc.
Common terms to describe transition: MTF – male-to-female (transgender women) FTM – female-to-male (transgender men) Genderqueer
Terminology and medical “transition”
Medical Diagnostic Terms Psychiatric Diagnoses
DSM IV – Gender Identity Disorder (302.85) Often perceived as pathologizing
DSM V – Gender Dysphoria Revised definition intended to depathologize by
focusing on feeling of incongruence (rather than behavior) and separating it from sexual dysfunctions and paraphilias
Medical Diagnoses Transsexualism ICD-9: 302.5x; ICD-10: F64.0
NB: Many clinicians avoid these diagnostic codes and use more neutral ones (i.e. Unspecified Endocrine Disorder 259.9)
Terminology and medical “transition” Medical Terminology Cross-Gender Hormone Therapy Not universally desired nor necessary (e.g. No-Ho)
Sex Reassignment Surgery (SRS) or Gender Confirming Surgery (GCS) Not universally desired (e.g. Non-op) Not easily obtainable: Cost/insurance coverage Need to meet criteria
Terminology and medical “transition”
Diverse Utilization of Surgery
Source: Grant et al., 2010: http://transequality.org/PDFs/NTDSReportonHealth_final.pdf
Feminizing Procedures
Terminology and medical “transition”
Diverse Utilization of Surgery
Masculinizing Procedures
Source: Grant et al., 2010: http://transequality.org/PDFs/NTDSReportonHealth_final.pdf
Creating a welcoming environment
What can we do?
Harassment
Family Rejection
Discrimination
Poverty
Lack of Health
Insurance
Sexual Assault Hate
Crimes
Wrongful Incarceration
Homelessness
Police Brutality
Domestic Violence
Creating a welcoming environment
Stressful Psychosocial Realities
Creating a welcoming environment
Barriers to Healthcare
Negative prior experience
Real and perceived hostility in healthcare settings
Real and perceived lack of
provider knowledge
ID/Identity mismatch
Lack of insurance/lack of hormone coverage
Immigration issues
Hours of clinics
Culture of self-sufficiency
Institutional settings- lack of transgender appropriate housing
Disproportionately affected by psychosocial stressors
Creating a welcoming environment
It’s not just a clinical issue Cultural competency and sensitivity training for
ALL staff
Transgender-sensitive and inclusive education brochures, prevention information available
Become familiar with local support resources
Especially for assisting with name or gender designation change
Front-Line Staff Training Tool www.lgbthealtheducation.org/publications
Creating a welcoming environment
Facilities Matter Unisex or single-use bathrooms
Creating a welcoming environment
Inclusive Forms
“We require the following information for the purposes of helping our staff use the most respectful language when addressing you, understanding our population better, and fulfilling our grant reporting requirements. The options for some of these questions were provided by our funders. Please help us serve you better by selecting the best answers to these questions. Thank You.”
No marital status question, but “partnered” would be an option if we had one.
Creating a welcoming environment
Use the preferred pronoun
Why is using the correct pronoun important? It is often stressful, frightening, and difficult for a patient to have to show, say, or write a name or gender that does not match their gender identity and chosen name, or disrobe, talk about body parts, and come out about transgender status.
Creating a welcoming environment
Use the preferred pronoun
Which pronoun is correct to use? Consider not using any pronouns (staff training) No better way to find out then to ask politely If you have to guess, ask your self what is this
person’s gender expression? Listen for new pronouns (hir, zie, s/he) and echo
back the language you hear Once you know the correct pronoun, make an
effort to use it consistently Everyone slips up; when you do, apologize and try
harder next time
Creating a welcoming environment
Examples of TG Sensitivity
Creating a welcoming environment
Inclusive Health Ed Materials
Review of Gender Biology
Setting the Stage for Hormones
Review of gender biology
Sex Hormones
17-Hydroxypregnenolone
Estradiol
Aldosterone
Dehydroepiandrosterone
∆4-Androstendione
Cortisol
11-Deoxycortisol
Testosterone
17-Hydroxyprogesterone
Progesterone
Acetate
Cholesterol
∆5-Pregnenolone
Plasma LDL Cholesterol
Review of gender biology
Hypothalamic-Pituitary-Gonadal Axis
Review of gender biology
Puberty
Hormonal transition recapitulates puberty Development of secondary sex characteristics Variable timeline Systemic process Unpredictable results
Review of gender biology
Puberty Tanner Stage Breast Changes Puberty Hormones I nipple elevation <11yo Pre-hormonal
II palpable breast buds; areolae enlarge
11yo (9-13)
Starting treatment
III elevation of breast contour; areolae enlarge
12yo (10-14)
6-12 months
IV areolae form secondary mounds
13yo (10.5-15.5)
1-2 years
V mature breast contour; areolae recess to general breast contour
16yo 2-5 years
1
2
3
4
5
Prescribing CGHT How to do it safely and effectively
Prescribing CGHT
Published Standards
Prescribing CGHT
Different Approaches Traditional Model Informed Consent Model Assignment of mental
health diagnosis (GID) Assignment of diagnosis of
Transsexualism Evaluation and clearance
for transition by mental health provider
Mandated psychotherapy Necessity of Real Life
Experience (RLE)
Pathologizing diagnoses not necessary
No clearance from mental health needed
No mandated psychotherapy
No RLE Prescription after medical
evaluation and obtaining informed consent
Prescribing CGHT
Initial assessment
Keep in mind: Transgender patients are likely to have had
previous negative healthcare experiences Developing trust and rapport may take longer than
you are used to Avoid genital and rectal exams on the first visit
whenever possible Be sensitive to dissociation from genitals Discuss choice of language to describe anatomy Don’t say “pre-op” or “post-op”
Prescribing CGHT Initial assessment
Thorough history and physical exam: Personal or family history of cardiovascular
disease, breast cancer, diabetes mellitus, hypertension
History of hepatitis, thromboembolic disease, or gallstones
History of prescribed or street hormone use History of depression, anxiety, or psychosis Alcohol, tobacco, and other drug use including
silicone injections and “pump parties”
Prescribing CGHT
Initial assessment
Initial laboratory exams: Basic chemistry, liver function tests, lipid profile,
hemoglobin/hematocrit Prolactin (for MTF), thyroid function, free
testosterone (for MTF) Hepatitis A, B, C, HIV, syphilis For FTM - Pap smear, gonorrhea/chlamydia screen
(does not need to be done in 1st appointment)
Prescribing CGHT Initial assessment
Counseling on minimizing modifiable risk factors: Smoking cessation Alcohol and drug use harm reduction Safer sex Proper nutrition and exercise
Prescribing CGHT Initial assessment
Thorough assessment of the patient’s psychosocial support system: Meeting with transgender care coordinator
when appropriate, if possible
Counseling and Education visit: Appointment with RN/health educator for
most patients Can also be done by mental health provider for
patients with mental health issues Can also be done by medical provider Review of alternatives to and risks/benefits of
cross-gender hormone therapy Discussion of realistic expectations of
physical changes
Prescribing CGHT Initial assessment
Prescribing CGHT
Initial assessment Once all components have been completed, patient
signs a specific informed consent and initial dose of hormones is prescribed
Stress on harm-reduction approach
Prescribing CGHT
Silicone Use >25% of transwomen inject
silicone to create a more “feminine” appearance
May be industrial grade and mixed with paraffin or cooking oil
Pump Parties – venues for sharing and injecting silicone
Risks: pulmonary embolism, ARDS, disfigurement, local infection, HCV, HIV, MRSA, mycobacteria
Prescribing CGHT
Appropriate follow-up Ongoing assessment of patient’s physical,
emotional, and psychological changes and reactions to hormone therapy
Ongoing assessment of the patient’s psychosocial support system
Ongoing counseling on minimizing modifiable risk factors
Prescribing CGHT
Appropriate follow-up Routine screening on all organs as long as they are present: Testicular and prostate* exam Pap smear and gonorrhea/
chlamydia screening Breast exams* and
mammograms Periodic syphilis, HIV, other
STI screening *not considered routine by current USPSTF guidelines
Prescribing CGHT
Appropriate follow-up
Periodic laboratory testing: MTF q6-12 mos: fasting glucose, lipid profile, liver
function, prolactin as needed: testosterone, potassium, hemoglobin
FTM q6-12 mos: fasting lipids, liver function,
hemoglobin
Prescribing CGHT
Appropriate referrals
Referrals to surgeons FTM: reduction mammoplasty, liposuction,
hysterectomy, salpingo-oophorectomy, vaginectomy, metoidioplasty, scrotoplasty, urethroplasty, phalloplasty, testicular prostheses
MTF: breast augmentation, tracheal shaving, orchiectomy, penectomy, vaginoplasty, clitoroplasty, labiaplasty, facial bone reduction, rhinoplasty, blepharoplasty, reduction thyroid chondroplasty
Prescribing CGHT
Cross-Gender Hormone Therapy
Prescribing CGHT
General Guidelines These medications and dosages are for use in the
adult population, not in adolescents still going through puberty
Slow escalation over first 2-3 months to full doses with frequent monitoring
Using hormones for gender transition is off-label; as with any medication, safety precautions and adequate monitoring are essential
Prescribing CGHT
General Guidelines Doses of testosterone and estrogen should be
decreased after orchiectomy or hysterectomy with oophorectomy
Anti-androgen agents may be discontinued after orchiectomy
After gonadectomy, sex hormones should be continued
Prescribing CGHT
Agents for FTM
Androgens – injectable Testosterone (cypionate or enanthate)
100-300mg (IM) every two weeks
Androgens – other Transdermal/Transmucosal Testosterone
(Androgel, Androderm, Testim, Striant, etc.) 5-10g daily or usual replacement dose
Impantable (Testopel) 150-450mg every 3-6 months
Prescribing CGHT
Agents for MTF Oral Estrogen Estradiol (Estrace)
6-8mg daily NB: Most potent estrogen
Conjugated estrogens 5-10mg daily NB: Mixture of nine estrogens; available from animal (Premarin) or plant (Cenestin) sources
Prescribing CGHT
Agents for MTF Oral Estrogen (continued) Esterified estrogens (Estratab, Menest)
5-10mg daily NB: Derived from modified soy
Ethinyl estradiol (oral contraceptives) NB: not recommended; significant drug interactions with HIV medications; very small dose of estrogen
Prescribing CGHT
Agents for MTF Injectable Estrogen Estradiol valerate (Delestrogen)
20-40mg (IM) every two weeks
Transdermal Estrogen Estrogen cream (Premarin) Estradiol patches (Climara, Estraderm)
50-100µg daily NB: expensive; difficult adherence
Implantable Estrogen Estradiol pellets
NB: limited experience; not approved
Prescribing CGHT
Agents for MTF Progesterone use is controversial in hormone transition. Many experts do not recommend it.
Oral Progesterone Medroxyprogesterone acetate (Provera)
10mg daily for 10 days every 28 Micronized progesterone (Prometrium)
200mg daily for 10 days every 28
Injectable Progesterone Medroxyprogesterone acetate (Depo-Provera)
150mg (IM) every six weeks
Prescribing CGHT
Agents for MTF Anti-Androgens Spironolactone (Aldactone)
100-400mg daily Risks: hyperkalemia, hypotension NB: K+-sparing diuretic; most popular anti-androgen; interferes with testosterone production and blocks androgen receptors
Flutamide (Eulexin) 250-750mg daily Risks: hepatic injury, bone marrow toxicity
Prescribing CGHT
Agents for MTF Anti-Androgens (continued) Leuprolide acetate (Lupron)
3.75mg (IM or SC) monthly NB: GnRH analog
Cyproterone acetate (not available in US)
Ketoconazole (Nizoral) NB: anti-fungal agent; risk of hepatic injury precludes its use for this purpose
Prescribing CGHT
Agents for MTF 5-α-Reductase Inhibitors Finasteride (Proscar, Propecia)
1-5mg daily Dutasteride (Avodart)
0.5mg daily NB: these agents decrease synthesis of 5-α-
dihydrotestosterone; more effective for hair re-growth than other secondary sex characteristics
Other agents with unproven or unclear efficacy that are popular or readily available on the streets Clomid Vitamin B12 Oral contraceptives HCG analogs Ketoconazole
Prescribing CGHT
Agents for MTF
Effects of CGHT What to expect in hormonal transition
Cross-gender hormone therapy
Androgenic therapy
Testosterone (FTM) Deepening of the voice Genital changes Irregular menses cessation of menses Clitoral enlargement Atrophic vaginitis
Increased libido Minimal breast atrophy Redistribution of fat from hips to waist
Cross-gender hormone therapy
Androgenic therapy
Testosterone (FTM) Increased upper body strength (with exercise) Integument Male-pattern facial and body hair growth Male-pattern hair loss
Psychological sense of well-being
Cross-gender hormone therapy
Androgenic therapy
Testosterone (FTM) Side effects: acne, headaches, weight gain,
fluid retention Risks: polycythemia, hepatotoxicity, worsening of
lipid profile and increased homocysteine level, emotional lability, infertility, insulin resistance
Cross-gender hormone therapy
Estrogenic therapy
Estrogens & Anti-androgens (MTF) Breast development Magnitude of enlargement is highly variable;
size beyond B cup is uncommon Maximum effect after two years
Integument Body hair diminishment Slowing, stopping, or reversal of androgenic
hair loss Softening of the skin
Cross-gender hormone therapy
Estrogenic therapy Estrogens & Anti-androgens (MTF) Fat redistribution to a gynecoid habitus (smaller
waist, wider hips) Reduction in upper body muscle mass and strength May result in loose skin for a short time Psychological sense of well-being No effect on beard hair Longer growth cycle and higher follicle density Electrolysis, laser or other hair removal
usually required
Cross-gender hormone therapy
Estrogenic therapy
Estrogens & Anti-androgens (MTF) Genital changes (chemical castration) Testicular atrophy Reduction in penis size Decrease in frequency and strength
of erections Decrease in volume and content of semen Reduction in prostate size
No effect on prominence of larynx No effect on pitch and resonance of voice
Cross-gender hormone therapy
Estrogenic therapy
Estrogens & Anti-androgens (MTF) Risks: thromboembolism, increased risk of breast
cancer?, hyperprolactinemia/pituitary adenoma, hepatotoxicity, cardiovascular risk?, infertility, anxiety/depression, gallstones, hypertension
Smoking increases risk of thromboembolism while on estrogen
Cross-gender hormone therapy
Estrogenic therapy Venous Thromboembolism Risk: Patients at higher risk for thrombotic events may benefit from using transdermal estrogen
Cases Controls Adjusted* OR
No use 145 384 1 Oral estrogen 45 39 4.2 (1.5-11.6) Transdermal estrogen
67 180 0.9 (0.4-2.1)
*Adjusted for obesity, family history of VTE, history of varicose veins, education, age at menopause, hysterectomy, and smoking. Circulation. 2007; 115:840-5
Cross-gender hormone therapy
Progestin therapy
Progestins Breast enlargement is the most common reason TG
women seek progesterone Role in CGHT is unclear Many clinicians do not use progestins for
hormonal transition Some clinicians use progestins for only the first
six months of transition Some use progestins cyclically (10/28 days) to
mimic the biological female cycle
Cross-gender hormone therapy
Progestin therapy
Progestins Side effects: weight gain, edema Risks: phlebitis, depression, mood swings,
androgenic effects WHI data on use of conjugated estrogens with
progesterone showed an increased risk of DVT, stroke, pulmonary emboli (PE) and myocardial infarction (MI)
Cross-gender hormone therapy
Safety of CGHT Use
Very few published studies of long-term safety of FTM or MTF regimens
2007 retrospective study from Netherlands12
30 years follow-up of 2236 MTF and 876 FTM
MTF: 20-fold increase (6-8%) in incidence of venous thrombosis on ethinyl estradiol; increase in PRL levels
FTM: polycythemia is rare; no change in mortality
Cross-gender hormone therapy
Key Points about CGHT
Hormones are: Vital to some TG patients’ identities
Safe
Effective
Not complicated to prescribe and monitor
Cross-gender hormone therapy
Key Points about CGHT
Providing hormones will result in: Improved mental health of your patients
Reduced risk behavior related to the acquisition of street hormones
Strengthen the provider-patient relationship
Improve adherence to other medical interventions
Acknowledgements
Rosalyne Blumenstein, CSW Carrie Davis, MSW Richard di Furia Nathan Levitt Barbra Ann Perina Jason Schneider, MD Anita Radix, MD Scout, PhD Hundreds of generous sharing patients
Thank you.
Additional Resources
The Gender Identity Project at The Lesbian, Gay, Bisexual & Transgender Community Center www.gaycenter.org/programs/mhss/gip.html
TransGender Care www.transgendercare.com/default.asp
Transsexual Women’s Resources www.annelawrence.com
Oriel, KA. “Medical Care of Transsexual Patients,” Journal of the Gay and Lesbian Medical Association, Vol 4., No. 4, 2000; [email protected]
Additional Resources
The World Professional Association for Transgender Health Standards Of Care for the Health of Trassexual, Transgender, and Gender Nonconforming People; Seventh Version, 2011 www.wpath.org/soc.html
Center of Excellence in Transgender Health transhealth.ucsf.edu/
For Ourselves Reworking Gender Expression FORGE www.forge-forward.org
Additional Resources
Transgender Health Program: Vancouver Coastal Health www.vch.ca/transhealth
Transgender Care www.transgendercare.com
True Selves: Understanding Transsexualism-For Families, Friends, Coworkers, and Helping Professionals, by Mildred L. Brown
National Center for Transgender Equality www.nctequality.org
Additional Resources
Sylvia Rivera Law Project www.srlp.org
Positive Health Project www.positivehealthproject.org
Trans Health www.trans-health.com
Transgender Health Initiative of New York www.transgenderlegal.org/our-work/health/thiny/
Trans 101: Transgender Law Center www.srlp.org/documents/TLC_new_trans_101.htm
Additional Resources
Trans Basics www.transfamily.org/trans.htm
Transgender Law Center www.transgenderlawcenter.org
Medical Therapy and Health Maintenance for Transgender Men: A Guide For Health Care Providers www.nickgorton.org
Transgender Care Conference hivinsite.ucsf.edu/InSite?doc=2098.473A